Telemedicine is a tool that can work wonders for all kinds of general and specialty care. And care for children with special needs and their families is no different.
Dr. Patricia Hayes is chief medical officer at Imagine Pediatrics, an organization that delivers healthcare for children with special needs. And telemedicine is a big part of her operation.
She knows how virtual care and remote monitoring can work for Medicaid-enrolled children with special healthcare needs – autism and beyond. She knows how to unpack what it takes to operationalize whole-child care at home through a virtual-first model that’s built for families who historically have been underserved.
We spoke with her recently to discuss why in her opinion episodic virtual visits miss the mark for children with special healthcare needs and what a continuous care model looks like instead; the real impact of virtual teams; why addressing emotional, behavioral and environmental challenges is essential to any remote care strategy; and how a virtual-first model is tailored to the realities of Medicaid families.
Q. You say episodic virtual visits often can miss the mark for children with special healthcare needs, and a continuous care model often is needed. What does this look like?
A. Episodic care can be effective for low-risk, short-term issues and quick check-ins. But when it comes to children with special healthcare needs, it’s just not enough. Their conditions rarely follow a straight line. And often these children have multiple comorbid conditions that can add more complexity.
One moment they’re stable, and the next, a small symptom or minor setback can snowball. Because of the heterogeneity of this vulnerable population, they can have higher needs for both acute and longitudinal support through ongoing, personalized care that adjusts with them and their needs.
That’s where a continuous and integrated care model is most effective. Instead of a rotating list of providers or one-off virtual visits, families now can build lasting connections with a consistent team. These clinicians know the child’s history, understand the family’s environment and recognize subtle shifts that might signal trouble.
It’s a proactive model – one that allows for early intervention and improved long-term outcomes, not just crisis management.
This care model isn’t just about frequency, but also depth. Clinicians stay engaged, working closely with behavioral health, care coordination and other support services to create a comprehensive plan. For families who’ve often felt let down by fragmented systems, that level of coordination through integrated medical, behavioral and social care can be a game-changer.
It builds trust, reduces stress and clinically leads to better outcomes. When we think of virtual care as an extension of a continuous relationship rather than a transaction, we unlock its true potential for the kids who need it most.
Q. Virtual teams certainly can have a real impact on healthcare. In your view, who should be on these teams and what do they do?
A. Imagine Pediatrics has a multidisciplinary team of experienced clinicians, like pediatricians, nurse practitioners, nurses, behavioral health professionals, therapists and social workers. Many of them come from hospitals or high-acuity outpatient settings and are used to working with children with special healthcare needs.
But what makes these teams truly effective isn’t just their clinical background – it’s how they work together.
They’re in sync, sharing context, learning from each other, and coordinating care in a way that’s actually helpful to families. And they’re proactive. Our predictive analytics and actionable data model helps our care delivery teams see changes in status before they become more serious issues.
If something looks off, they don’t wait for a scheduled visit, they reach out. That kind of attentiveness is rare in most healthcare settings and can help families navigate a system that can often feel overwhelming.
With the right structure, virtual teams aren’t just a stopgap for in-person visits, they’re a lifeline. They offer families better access, stability, reliability and real-time help from professionals who understand both the clinical landscape and the human one.
Q. You suggest addressing emotional, behavioral and environmental challenges is essential to any remote care strategy. Why is that? What difference can it make?
A. You can’t separate medical care from everything else going on in a family’s life, especially when you’re talking about children with special healthcare needs. I’ve seen families manage a child’s chronic condition beautifully from a clinical perspective, but still fall behind because of housing issues, caregiver burnout or a lack of mental health support. If a care plan doesn’t account for those realities, it’s not going to work long term.
This is where remote care has the potential to go deeper. When a team has visibility into behavioral and environmental factors along with the tools to respond, care becomes more personalized and more effective.
That means recognizing when a parent is overwhelmed, when food insecurity is creeping in or when a child might benefit from behavioral health services. And instead of handing families off to another department, the team helps them navigate those challenges directly.
Most families won’t describe what they need in clinical terms. They won’t ask for “integrated care” or “social determinant screening.” What they want is someone who listens, follows up and sees the whole picture. When that happens, you build trust. And that trust keeps families engaged, improves adherence and ultimately improves outcomes.
Q. How should a virtual-first model be tailored to the realities of Medicaid families, including tech access, language needs and trust-building?
A. This is where we really need to rethink our assumptions. A virtual-first model sounds great in theory – but if we’re not designing it around what families actually have access to, we’re going to miss the mark.
Families often face any number of barriers – unreliable or no internet access, language differences, transportation issues, healthcare literacy challenges, or demanding work schedules. So, we need to start practically and lead with listening.
One of the most impactful choices we can make is prioritizing continuity. When families hear a familiar voice – someone who knows their child and their story – it builds trust. When they feel heard, it builds relationships and a sense of relief for the caregiver.
That familiarity is essential, especially for families who may have experienced inconsistent care in the past. It’s not just about being reachable – it’s about being reliable and relational.
We also need flexibility. Some families prefer phone calls. Others might want home visits. Some need communication in another language, or a different tone, or just a little extra time to explain or understand things.
We have to build that layer of family-centered personalization into the system to truly provide integrated care in a way that enables children to have more safe days at home and less time in preventable hospital stays.
The integration of care needs to include collaboration between a child’s existing providers and specialists and the rest of their care team to work effectively. A partner who delivers integrated care won’t replace the child’s primary care provider or specialists but will wrap around their care plan to provide an additional layer of support and resources. When a family experiences this kind of collaborative coordination, trust is built.
Virtual-first doesn’t mean digital-only or one-size-fits-all. It means we’re leading with expanded access while designing and evolving our care model around what works best for children with special healthcare needs and their caregivers.
And when we do that, we don’t just improve care and expand access, we are setting the framework for how virtual care can and should be delivered across the healthcare ecosystem.
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Healthcare IT News is a HIMSS Media publication.
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